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Application for Onsite Date Stampp 6-bl.DIXD-5 <br /> -- =� Wastewater Treatment System <br /> MARION COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE AUG 1 Z024 <br /> Salem OR 97305 <br /> (503)588-5147 Fax(503)588-7948 <br /> www.co.marion.or.us/PW/BuildingInspection <br /> ( Pro�ertOwner=Infoi matioa. , ',. _ <br /> Andrey Kaya 19965 Butteville Rd NE <br /> Name Mailing Address <br /> Hubbard, OR 97032 5039517887 <br /> City,State,and Zip (Area Code)Phone# <br /> , ,2 : . <br /> 18936 Butteville Rd NE Aurora OR 97002 <br /> Property Address City State Zip Code <br /> LOT 1 <br /> Parcel# Tax Lot Acreage or Lot Size <br /> Directions to Property: <br /> CExisttng FacilProposedacilify,%WaterInforniatian M__ .. - _ .. `] <br /> Existing Residential: Proposed Residential: Existing Commercial: Proposed Commercial: Water Supply: <br /> 4 ['Public <br /> Name <br /> Number of Bedrooms Number of Bedrooms Number of Employees/ Number of Employees/ 0 private WELL <br /> Seating Seating <br /> Well,Spring,Shared <br /> D TyEe of ALplicstiori:' M <br /> ❑ Site Evaluation ❑ Renewal Permit ['Authorization Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> ❑ Alteration Permit ❑■ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other ❑ Connecting to an Existing System Never in Use <br /> (over 5-yrs old) <br /> ❑ Other—Please Specify <br /> If the required fee and attachments are not included with this application, it will be returned to you as incomplete. <br /> Post the orange card at the entrance to the property. Flag the test holes. <br /> By my signature,I certify that the information I have furnished is correct,and hereby grant Marion County,authorized agent of the <br /> Department of Environmental Quality,permission to enter onto the above described property for the sole purpose of this application. <br /> Andrey Kaya 5039517887 <br /> Applicant's Name—Please Print Legibly Applicant's Phone Number DEQ Lic.#(if applicable) <br /> 19965 Butteville Rd NE andrey_kaya@outlook.com <br /> Applicant's Mailing Address Email: <br /> Signature Date: CCB# (if applicable) <br /> Applicant is the ❑■ Owner ❑Authorized Representative(form attached) <br /> HTTPS://MARIONCOUNTYGCC-MY.SHAREPOINT.COM/PERSONALBREICH_CO_MARION_OR_US/DOCUMENTS/DESKTOP/S-01 ONSITE APPL <br /> AUGUST 2024 REV 8.24.DOCX Rev 1/15,3/18,6/22,6/23,8/24 <br />